Elsevier

Injury

Volume 41, Issue 11, November 2010, Pages 1150-1155
Injury

Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing

https://doi.org/10.1016/j.injury.2010.09.026Get rights and content

Abstract

We studied 80 patients (56 females) with an average age of 84 years (range 80–94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55 g/dL and 1.05 g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery.

Introduction

Lately, the incidence of proximal femoral fractures has substantially risen in the elderly.9, 13, 14, 15, 22, 40 This rise has been attributed to an increase in their life span and the underlying poor bone stock and osteoporosis.19, 29 It has been estimated that by the year 2040 the incidence of these fractures in the elderly will have doubled and this would cause a great burden on the national health care systems.8, 33

Due to the poor bone quality the vast majority of these fractures result following a simple fall.6 Fixation of proximal femoral fractures with a sliding screw plate or nail remains the gold standard of treatment.7, 26, 27, 30, 31 The latest generation of implants are considered more elastic and have a lower rate of complications due to their mechanical characteristics and controlled telescopic movement for the fracture impaction during weight-bearing.

One of the main reason for revision surgery which has been reported to be as high as 16% is the cut-out of the fixation device at the apex of the femoral head.1, 23, 24, 25, 32, 34 Several internal fixation techniques have been developed to avoid this complication such as double or convergent screws. Recently, augmentation of the weak bone with PMMA or calcium phosphate cement has been studied in vitro and in clinical trials. Augmentation was facilitated by injecting the cement or the bone substitute at the level of the neck of the femur. Whilst augmentation is considered as a useful method with regard to the increase purchase between the bone and implant interface, drawbacks have also been discussed including the development of thermal necrosis and impaired fracture healing due to the exothermic reaction induced by the cement material.19 Furthermore, removal of the cement might by a problem in cases where revision surgery would be necessary.2, 17, 21, 23 Despite the above concerns, experimental trials on human cadaveric proximal femurs augmented with a low viscosity PMMA bone cement have demonstrated that loading the femoral head in a physiological manner beginning at 1500–4000 N caused head displacement for non-augmented implants in all the cases studied, whereas 50% of the augmented implants did not fail.11, 18, 19, [42] These experiments have suggested that the augmentation method enhances the implant anchorage in osteoporotic bones.

The aim of this prospective randomised study therefore was to evaluate the clinical and radiological results of a cement augmentation method of internally fixed unstable intertrochanteric fractures in osteoporotic elderly patients compared with the conventional internal fixation without any augmentation.

Section snippets

Materials and methods

The study was performed between January 2006 and March 2010. We treated 80 patients (24 males, mean age 84 (80–94) who sustained unstable trochanteric fractures (A2.1, A2.2, A2.3, A3). Inclusion criteria were an unstable trochanteric fracture, defined as fracture with three parts or more, age more than 80 years and a Singh score of 1 or 2.36 Exclusion criteria were dementia, neuromuscular or musculo-skeletal deficiency which could limit the ability to perform objective functional tests,

Results

In group A the average HHS score before the fracture was 56.49 (range 19–89), 48.2 after 1 month post-operation (range 17–88), 54.28 after 3 months (range 25–88), 54.71 after 6 months (range 27–87), and 57.91 after 12 months (range 29–88) (Table 1). In group B the HHS score before fracture was 56.75 (range 20–89), 49.31 after 1 month (range 18–87), 53.56 after 3 months (range 24–87), 56.42 after 6 months (range 29–88) and 59.86 after 12 months (range 32–89) (Table 2).

Analysis of haemoglobin and

Discussion

The management of unstable trochanteric fractures is challenging to the most experienced trauma surgeons. Surgery may be delayed due to associated co-morbidities and peri-operative complications could not be underestimated in this cohort of patients. Moreover, the poor bone stock frequently seen in these patients may compromise the mechanical environment of the fracture.

The degree of underlying osteoporosis was evaluated from the pelvic AP radiographs by assessing the Singh index. We did not

Conclusion

Implantation of PMMA cement for augmentation of the sliding screw during fixation of intertrochanteric fractures appears to be a safe method with good clinical outcome. It allows patients to have a faster rehabilitation and a shorter period of hospitalisation. Further larger scale studies will throw more light into the efficacy of this technique and the health economic benefits to the society and each individual health care system.

Conflict of interest

The author did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from commercial entity.

References (43)

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